Palmcrest Grand Residence.

On 07/01/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Collateral Visit to the facility listed above. LPA met with Peggy Clark, Administrator, and the purpose of today's visit was explained. LPA was granted entry into the facility. LPA conducted a visit to the facility to interview Resident R1 regarding a complaint (11-AS-20260309160817) at their previous residence. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report was provided.

On 5/21/2026, at 11:00 am, a virtual meeting was held to discuss Complaint 11-AS-20250606143306. Present at the meeting was Eva Alvarez, Licensing Program Manager (LPA), Alfonso Iniguez (LPA), Veronica Gomez Executive Director, Rachel Streicher, Licensee and Joel S Goldman, Attorney. During the meeting, LPM reviewed the details of the Complaint. On February 20,2026 the Department substantiated an allegation(s) of Staff neglect resulting in a resident being hospitalized and Staff did not address a resident's change in medical condition. At the time the findings were delivered on February 20, 2026, the Department indicated that an enhanced civil penalty determination was pending, pursuant to Health and Safety Code Section 1569.49(f). An exit interview was conducted, and an electronic copy of this report was provided to Veronica Gomez via email.

This report supersedes the report created 4/7/26 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Staff did not provide adequate supervision to resident in care The details of the complaint alleged that facility staff are not providing adequate supervision to (R#1) On April 7, 2026, at approximately 3:00 p.m., during the records review process the department reviewed a copy of (R#1)’s Admission Agreement dated 6/2/2025. The department noted that (R#1)’s personal representative signed for basic services only, which include care and supervision, personal assistance and care, and continuous monitoring and observation. The agreement also states that extra care and supervision are available upon request for an additional charge. The department noted that, in this case, the facility has been providing 1:1 care and supervision to (R#1) without charging (R#1)’s personal representative for the additional service. In addition, the department reviewed copies of the facility’s internal incident reports regarding (R#1), documented on various dates, and noted that the facility has recorded all incidents involving (R#1). The department also reviewed a copy of (R#1)’s Resident Appraisal (LIC 603A) dated 2/18/2026, which indicates that (R#1) requires assistance with transferring in and out of bed, bathing, redirection inside the facility, special diet needs, toileting, continence care, medication assistance, and other services as needed. On April 7, during an interview with the facility administrator (A#1), (A#1) stated that the facility provides supervision to residents based on their assessed needs. For residents receiving the basic rate, staff check on them every hour. Residents with higher levels of care are checked every 30 minutes to one hour. (A#1) stated that (R#1) receives one-on-one supervision. in addition, (A#1) further explained that although one-on-one supervision typically requires an additional charge, (R#1)’s family is not paying for this service, and the facility is providing it “out of good faith.” (A#1) stated that (R#1) has one-on-one care and supervision in place and is identified as a fall risk. (A#1) added that (R#1)’s primary physician’s nurse comes to the facility every day to check on her. Moreover, (A#1) stated that the facility has a supervisor on every shift. Staff reports all resident events, including incidents involving (R#1), to the shift supervisor, who is responsible for documenting and evaluating the occurrence. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 This report supersedes the report created 4/7/26 and the findings will remain unchanged. On April 7, during interviews with residents in care (R#2 through R#8), (7) out of (7) residents stated that staff supervise them appropriately. Residents reported that staff “do a very good job” and check on them regularly. All residents interviewed stated that they had never felt they were not being watched, helped, or supervised when needed. In addition, (7) out of (7) residents also reported no issues with staff being unavailable, delayed, or unresponsive, stating that staff are always present to assist them. On April 7, 2026, during interviews with facility staff (S#1 through S#4),(4) out of (4) facility staff stated that they provide supervision to residents according to their needs, including (R#1), they also reported that their responsibilities include assisting residents with changing clothes, changing diapers, and preparing residents for meals. In addition, they stated that staff consistently provide supervision due to residents’ cognitive impairments and reported that (R#1)’s behavioral expressions require staff to be more aware of her needs and provide close monitoring. Moreover, (4) out of (4) facility staff stated that they have not observed any challenges or gaps in maintaining appropriate supervision for (R#1) or for any other residents in care. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/ Facility Administrator.

The investigation revealed the following: Allegation 1: Staff did not provide 60-days’ notice prior to rent increase. On 4/8/2026 at 8:45 AM, the department reviewed documents and resident 1(R1) file which revealed in the admission agreement signed and dated 3/23/2023 and addendums dated 3/20/2023 which does disclose the responsibilities of the resident and/or responsible parties signed and dated on 3/17/2023, the department also observed documentation of 60-day notices for the monthly rent change with effective dates of January 1,2024 and January 1,2025 and Valley Best Care Inc. hospice care files which reflect that care was provided from 12/7/2023-9/11/2025. At 2:00-5:00 PM, the department attempted to interview resident1 (R1) but they no longer live at the facility while residents 2- 4 (R2-R4) stated that they were not sure because their representatives handle their personal business with facility. Residents 6- 10 (R6-R10) stated that they do receive notification of monthly increase in writing annually and that they were aware of this information being within their admission agreement. The department also conducted interviews with ten (10) Staff members (S1-S10) and 4 out of 10 staff stated that they were not sure if a 60day notice of rent increase is given to residents in care and the remaining 6 staff members (S6-S10) stated residents and/or their representatives are informed annually about their monthly increase in writing which is also in their admission agreements. On 4/9/2026 at 12:30PM, During the visit the department reviewed 5 residents files for current documentation that reflect 60-day notices of annual rent increase/eviction which is within admission agreements, and current care records and based on the observations all 5 files were up to date. The investigation revealed the following: Allegation 2: Staff do not keep an accurate care record. On 4/8/2026 at 8:45 AM, the department reviewed documents and resident 1(R1) file which revealed in the admission agreement signed and dated 3/23/2023 and addendums dated 3/20/2023 which does disclose the responsibilities of the resident and/or responsible parties signed and dated on 3/17/2023, the department also observed documentation of 60-day notices for the monthly rent change with effective dates of January 1,2024 and January 1,2025 and Valley Best Care Inc. hospice care files which reflect that care was provided from 12/7/2023-9/11/2025. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 At 2:00-5:00 PM, the department attempted to interview resident1 (R1) but they no longer live at the facility while residents 2- 4 (R2-R4) stated that they were not sure if the facility keeps accurate care records because their representatives handle their personal business/care with facility. Residents 6- 10 (R6-R10) express confidence that the facility staff does keep accurate care records. The department also conducted interviews with ten (10) Staff members (S1-S10) and 4 out of 10 staff expressed confidence that residents are accurate. Staff reported that when residents have a change of condition Medtech’s are informed and documented and if required needs and service plans are updated. On 4/9/2026 at 12:30PM, During the visit the department reviewed 5 residents files for documentation that reflect 60-day notices of annual rent increase/eviction which is within admission agreements, and current care records and based on the observations all 5 files were up to date. LPA also attempted to contact Valley Best Care, Inc., but the department was unable to speak to a representative during the investigation. The department did however review Valley Best Care Inc. hospice care files which reflect that care was provided from 12/7/2023-9/11/2025. The investigation revealed the following: Allegation 3: Facility admission agreement does not have eviction or rent increase procedure. On 4/8/2026 at 8:45 AM, the department reviewed documents and resident 1(R1) file which revealed in the admission agreement signed and dated 3/23/2023 and addendums dated 3/20/2023 which does disclose the responsibilities of the resident and/or responsible parties signed and dated on 3/17/2023, the department also observed documentation of 60-day notices for the monthly rent change with effective dates of January 1,2024 and January 1,2025 and Valley Best Care Inc. hospice care files which reflect that care was provided from 12/7/2023-9/11/2025. At 2:00-5:00 PM, the department attempted to interview resident1 (R1) but they no longer live at the facility while residents 2- 4 (R2-R4) stated that they were not sure because their representatives handle their personal business with facility. Residents 6- 10 (R6-R10) stated that their admissions agreement does reflect the annual monthly increase, and 60-day notices are given to them in writing in advance. Continued 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The department also conducted interviews with ten (10) Staff members (S1-S10) and 4 out of 10 staff stated that they were not sure if resident admissions agreements list the procedures for eviction/ 60day notice of rent increase and the remaining 6 staff members (S6-S10) stated residents and/or their representatives are informed annually about their monthly increase in writing which is also in their admission agreements. On 4/9/2026 at 12:30PM, During the visit the department reviewed 5 residents files for documentation that reflect 60-day notices of annual rent increase/eviction which is within admission agreements, and current care records and based on the observations all 5 files were up to date. Based on the interviews, records reviewed and observations the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is determined to be Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Veronica Gomez-Administrator at the conclusion of the visit with appeal rights.

Investigation Revealed the Following: Allegation: Staff did not provide adequate supervision to resident in care The details of the complaint alleged that facility staff are not providing adequate supervision to (R#1) On April 7, 2026, at approximately 3:00 p.m., during the records review process the department reviewed a copy of (R#1)’s Admission Agreement dated 6/2/2025. The department noted that (R#1)’s personal representative signed for basic services only, which include care and supervision, personal assistance and care, and continuous monitoring and observation. The agreement also states that extra care and supervision are available upon request for an additional charge. The department noted that, in this case, the facility has been providing 1:1 care and supervision to (R#1) without charging (R#1)’s personal representative for the additional service. In addition, the department reviewed copies of the facility’s internal incident reports regarding (R#1), documented on various dates, and noted that the facility has recorded all incidents involving (R#1). The department also reviewed a copy of (R#1)’s Resident Appraisal (LIC 603A) dated 2/18/2026, which indicates that (R#1) requires assistance with transferring in and out of bed, bathing, redirection inside the facility, special diet needs, toileting, continence care, medication assistance, and other services as needed. Moreover, the department reviewed a copy of (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A) dated 5/30/2025. The department noted that the physician indicated (R#1) has a diagnosis that contributes to their thinking and belief system. On April 7, during an interview with the facility administrator (A#1), (A#1) stated that the facility provides supervision to residents based on their assessed needs. For residents receiving the basic rate, staff check on them every hour. Residents with higher levels of care are checked every 30 minutes to one hour. (A#1) stated that (R#1) receives one-on-one supervision. in addition, (A#1) further explained that although one-on-one supervision typically requires an additional charge, (R#1)’s family is not paying for this service, and the facility is providing it “out of good faith.” (A#1) stated that (R#1) has one-on-one care and supervision in place and is identified as a fall risk. (A#1) added that (R#1)’s primary physician’s nurse comes to the facility every day to check on her. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Moreover, (A#1) stated that the facility has a supervisor on every shift. Staff reports all resident events, including incidents involving (R#1), to the shift supervisor, who is responsible for documenting and evaluating the occurrence. On April 7, during an interview with Witness 1 (W#1), (W#1) stated that during her visits to (R#1), she observed (R#1) in her room with the curtains closed and not participating in daily activities. (W#1) reported finding (R#1) in bed, not fully clothed, wearing only a diaper, and uncovered. (W#1) stated that she asked (R#1) if she was okay, and (R#1) replied, “I’m cold.” (W#1) reported that during one visit, it was already 10:00 a.m., and (R#1) was still in bed and had not eaten anything. (W#1) stated that she typically visits between 10:00 a.m. and 12:00 p.m. once a week. In addition, (W#1) stated that during the times she has visited, she has noticed that facility staff are not available most of the time. (W#1) stated that she is only aware of the conditions she has personally observed during her weekly visits and stated that during those times, she has observed occasions where (R#1) did not appear to be adequately cared for. On 4/7/26, the department was not able to speak with (R#1) due to their cognitive impairment. On April 7, during interviews with residents in care (R#2 through R#8), (7) out of (7) residents stated that staff supervise them appropriately. Residents reported that staff “do a very good job” and check on them regularly. All residents interviewed stated that they had never felt they were not being watched, helped, or supervised when needed. In addition, (7) out of (7) residents also reported no issues with staff being unavailable, delayed, or unresponsive, stating that staff are always present to assist them. On April 7, 2026, during interviews with facility staff (S#1 through S#4),(4) out of (4) facility staff stated that they provide supervision to residents according to their needs, including (R#1), they also reported that their responsibilities include assisting residents with changing clothes, changing diapers, and preparing residents for meals. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In addition, they stated that staff consistently provide supervision due to residents’ cognitive impairments and reported that (R#1)’s behavioral expressions require staff to be more aware of her needs and provide close monitoring. Moreover, (4) out of (4) facility staff stated that they have not observed any challenges or gaps in maintaining appropriate supervision for (R#1) or for any other residents in care. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/ Facility Administrator.

On 03/06/26 Licensing Program Analysts (LPAs) Day and Villegas conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPAs met with Veronica Gomez, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 262 residents ages 60 and over, of which 262 maybe non ambulatory and 10 maybe bedridden. The facility has an approved hospice waiver for 10 residents. Facility fees are current, liability insurance is active (PLC7094972231 exp: 02/28/27). LPA's obtained a copy of current lease agreement for the facility. The facility is a large, two story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of (2) floors which include resident rooms, common areas, dining area, kitchen, salon, game room and employee break room, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of (2) floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living quarters. Common areas were clean and clear of hazards, doorways were free of obstructions, there are no bodies of water nor weapons on the premises. LPAs toured the following resident bedrooms # 105, 104, 112, 301A, 301B, 303 and 305 and observed all required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 107.2F.. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Fire and safety service conducted on 02/27/26, LBFD fire protection and life safety equipment performance certificate obtained on 05/09/25. Fire extinguishers observed throughout the facility, first aid kit and manual are available. LPAs reviewed (10) resident files, (7) medication administration records (MAR), and (5) staff files. No Deficiencies were observed during this visit. Exit interview conducted with Veronica Gomez, Administrator. A copy of this report was provided at time of visit.

Investigation Revealed the Following: Allegation: Staff did not address a resident's change in medical condition The details of this complaint alleges that the facility failed to re-assess (R#1) after multiple falls. On October 30, 2025, the department conducted a review of medical records and found the following: On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom. The hospital performed imaging tests that revealed no fractures. (R#1) was discharged the same day. On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment and discharged February 7,2025. On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital and was discharged the same day. On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle. (R#1) was discharged the same day with documentation indicating orthopedic surgery would be scheduled. On June 5, 2025, (R#1) returned to the hospital due to injury-related pain. On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls. On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls. On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls. On September 2, 2025, the Department interviewed two facility caregivers, (S#1) and (S#2), regarding the care and supervision of (R#1). (S#1) reported that the only change (S#1) recalled was relocating (R#1) from the second floor to a first-floor room. (S#1) confirmed they received no additional instructions or updates regarding (R#1)’s care, supervision, or monitoring requirements. Similarly, (S#2) reported that they were only told to “keep a close eye” on (R#1) but received no formal or detailed instructions regarding changes to (R#1)’s supervision or care plan following the falls. Both staff members denied being informed of any structured plan to address (R#1)’s fall risk, and neither reported receiving training or direction specific to (R#1)’s condition or needs. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On September 2, 2025, the Department interviewed two facility caregivers, (S#1) and (S#2), regarding the care and supervision of (R#1). (S#1) reported that the only change (S#1) recalled was relocating (R#1) from the second floor to a first-floor room. (S#1) confirmed they received no additional instructions or updates regarding (R#1)’s care, supervision, or monitoring requirements. Similarly, (S#2) reported that they were only told to “keep a close eye” on (R#1) but received no formal or detailed instructions regarding changes to (R#1)’s supervision or care plan following the falls. Both staff members denied being informed of any structured plan to address (R#1)’s fall risk, and neither reported receiving training or direction specific to (R#1)’s condition or needs. Allegation: Staff neglect resulted in a resident being hospitalized The details of the complaint allege that facility staff failed to appropriately respond to changes in condition for (R#1), following multiple falls. On October 30, 2025, the department conducted a review of medical records and found the following: On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom. On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment. On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital. On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During this investigation, the department found sufficient evidence to support the above-mentioned allegation(s). Therefore, the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). *Immediate Civil Penalty issued* At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident. An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/Executive Director.

Observations revealed the following: During the tour, the LPA observed activity posters with daily exercise schedules prominently displayed and one activity happening in the activity area with residents participating. Records Review: LPA reviewed the Resident Appraisal which confirmed R1 "Exercises Daily" and Enjoys Group Activities. Medical Records: A Discharge Summary dated (01/02/2026) showed that R1 had recently improved health after being treated for heart and lung issues. The records show "highly involved" in activities. While mostly independent, staff help with "guided maneuvering," which means they help move her arms and legs during exercises to keep safe. Interviews: 10 out of 10 staff members (S1–S10) interviewed disagreed with the allegation. S6 stated that exercise videos and scheduled sessions are provided daily. Residents R1 and R2 indicated they participate in volleyball and daily exercises. Interviews with 10 residents (R1–R10) disagreed with the allegation. Witness W1 mentioned speaking with R1 regarding their enjoyment of the facility’s yoga and other activities participated in facility. During this investigation, the LPA did not find sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation is unsubstantiated. Regarding the allegation “staff is not assisting resident with exercising” It is alleged that the resident was not being assisted when walking down the stairs. Observations revealed the following: LPA verified and tested two functional elevators available for resident use. No residents were observed utilizing stairs during the course of the investigation. Interviews revealed the following: Staff members S5 and S8 indicated that residents utilize two facility elevators for floor-to-floor transport, as stairs are considered hazardous and are not the primary means of egress for residents. While R1 shared concerns of feeling "secondary," they acknowledged receiving staff help and stated they use the elevator rather than the stairs. Records Review: The Resident Appraisal noted R1 has "Improved Physically" and "can ambulate independently." The Physician’s Report verified R1's status as "Ambulatory." Facility records show the resident is independent in mobility with the use of a walker and does not have a physician-mandated requirement for stair assistance. Because of recovering from breathing problems, using the elevator was actually the safest choice for health. There was no medical requirement to use the stairs, and was able to move around the facility safely without that specific help. During this investigation, the LPA did not find sufficient evidence to support the above-mentioned allegation. Please see (LIC9099-C) for report continuation. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the evidence gathered, interviews conducted, and records reviewed, there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the Complaint Report was provided to Administrator Veronica Gomez.

This report supersedes the report created 10/10/25 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Licensee does not ensure that staff have criminal clearance The detail of the complaint alleges that (MW#1) is using another person's name and criminal background clearance to work at the facility. On October 10, 2025, at approximately 1:00 PM, during a review of facility records, Licensing Program Analyst (LPA) Iniguez reviewed the Personnel Report (LIC 500) dated September 1, 2025. Upon review, LPA Iniguez observed that (MW#1) was not listed on the LIC 500. On October 10, 2025, at approximately 10:00 AM, during an interview, the facility administrator (A#1) stated that individual (MW#1) is an outside contractor hired by the facility owner and is not a facility employee. According to (A#1), (MW#1) is present at the facility approximately four times per week and remains on-site for about seven hours per visit. (A#1) confirmed that (MW#1) performs contracted maintenance work inside the facility. Additionally, (A#1) stated that when (MW#1) is inside the facility, they are never alone inside residents’ rooms and always work in the common areas, where there is consistent supervision by facility staff. On October 10, 2025, at approximately 11:00 AM, during interviews with facility staff, (5) out of (5) staff members stated that they are familiar with individual (S#1) and observe them at the facility approximately three to four times per week. Additionally, all five staff members reported that whenever they have seen (S#1), the individual is observed in the common areas where there is consistent supervision by facility staff. Staff further stated that when residents request the maintenance person to enter their rooms, (S#1) is never unaccompanied, there is always a caregiver present during those instances. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 This report supersedes the report created 10/10/25 and the findings will remain unchanged. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Peggy Clark/Administrator.

On October 10, 2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. LPA Iniguez met with Facility Administrator Veronica Gomez and explained the purpose of the visit. During a subsequent complaint investigation related to complaint control number 11-AS-20250811090913 , LPA Iniguez discovered through interviews with the facility administrator (A#1) and facility staff (S#2–S#6) that individual (MW#1) comes to the facility approximately four to five times per week and spends about six hours per day on-site during each visit. LPA Iniguez informed the facility administrator that it could be a potential issue for an outside contractor to spend that amount of time at a licensed facility without having a criminal background clearance, as required by applicable regulations. As a result, a Technical Violation was issued during this visit. A copy of this report was provided to Veronica Gomez, Facility Administrator.

Investigation Revealed the Following: Allegation: Licensee does not ensure that staff have criminal clearance The detail of the complaint is alleging a maintenance worker is associated with a false name and criminal record clearance number. On October 10, 2025, at approximately 1:00 PM, during a review of facility records, Licensing Program Analyst (LPA) Iniguez reviewed the Personnel Report (LIC 500) dated September 1, 2025. Upon review, LPA Iniguez observed that (MW#1) was not listed on the LIC 500 since they are a third party provider. On October 10, 2025, at approximately 10:00 AM, during an interview, the facility administrator (A#1) stated that individual (MW#1) is an outside contractor hired by the facility owner and is not a facility employee. According to (A#1), (MW#1) is present at the facility approximately four times per week and remains on-site for about seven hours per visit. (A#1) confirmed that (MW#1) performs contracted maintenance work inside the facility. Additionally, (A#1) stated that when (MW#1) is inside the facility, they are never alone inside residents’ rooms and always work in the common areas, where there is consistent supervision by facility staff. On October 10, 2025, at approximately 11:00 AM, during interviews with facility staff, (5) out of (5) staff members stated that they are familiar with individual (MW#1) and observe them at the facility approximately three to four times per week. Additionally, all five staff members reported that whenever they have seen (MW#1), the individual is observed in the common areas where there is consistent supervision by facility staff. Staff further stated that when residents request the maintenance person to enter their rooms, (MW#1) are never unaccompanied, there is always a caregiver present during those instances. Evaluation Report continues LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Veronica Gomez/Administrator.

On 8/20/25, at 10:15 am. LPA Lee interviewed Veronica Gomez (A1), who denied the allegation stating that all staff are criminally cleared and associated to the facility. LPA was able to confirm that there are no employees by the names indicated in the complaint currently on staff at the facility. LPA confirmed this by reviewing the staff roster and Licening Information System (LIS) personnel report. On 8/20/2025, from 10:30am-12:00pm, LPA Lee conducted a review of the Personnel Report LIC 500 (dated 4/2025). During this review, all staff members were cross-referenced using the Licensing Information System (LIS) and the Community Care Licensing Guardian System. The results confirm that all staff members have obtained Criminal Record Clearance. Based on record review and interview conducted, there is insufficient information to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANIATED No deficiencies cited during today's visit. Exit interview conducted and copy of report provided to Veronica Gomez, Administrator. Page 2 of 2

On April 23, 2025, Licensing Program Analyst (LPA), Deborah Lee conducted an unannounced annual required visit using the CARE Inspection Tool. LPA Lee met with the Administrator Peggy Clark and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10. The census for today is 143. Physical Plant/Structure The facility is a large, two story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which include resident rooms, common areas, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living units. Bedrooms LPA inspected seven ( 7) resident rooms, 146, 147, 148, 117, 311, 301, 303 and observed them to be clean and in good repair. LPA observed all rooms to be properly furnished with a bed, dresser, night stand, chair, and storage space for resident’s personal belongings 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. The facility has an ample supply in a storage room for resident use. All rooms were observed with ample lighting. Bathrooms LPA inspected seven (7 ) resident bathrooms and observed them to be clean, operational, and meet Tittle 22 regulations. LPA found that in one of the hall bathrooms there was a missing toilet tank cover and a missing faucet handle. LPA observed storage area for residents’ personal hygiene products. The facility does have an ample supply of hygiene products available for residents. The water temperature in the resident’s bathrooms measured between 105-degrees and 120-degrees Fahrenheit. Common Rooms LPA inspected all common rooms in the facility and observed them to be properly furnished to accommodate all residents. LPA observed all walkway and hallway in the facility to be clean, clear, and free of obstructions and hazards. LPA observed all common areas to have ample lighting. The facility was kept at a comfortable temperature. LPA observed resident’s participating in activities and observed activity schedule posted in various locations of the facility. Kitchen LPA inspected the facilities industrial kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of cook ware, dishware, and cutleries. LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Safety LPA observed multiple fully charged fire extinguishers throughout the facility last serviced on 2/25/25. The last inspection from Fire Alarm and Safety System was conducted on 10/31/24. The last emergency drill was conducted on 2/11/25. The elevator was last inspected and serviced on 8/2/24. The generator is ran and checked on a weekly basis; it was last inspected during the annual service on 4/5/25. LPA observed all required documents posted throughout the facility. The facility has a working landline telephone. Due to time restraints, LPA to complete inspection on subsequent visit. During today’s visit, there was 1 technical violation issued; see: LIC9102TV An exit interview was conducted with Peggy Clark Administrator and a copy of this report was provided. Page 3 of 3

The investigation revealed the following: Allegation: Staff did not ensure resident’s bed was working properly. The detail of the complaint alleges that R1’s medical bed doesn’t work and hasn’t been working for three weeks and R1 had developed back sores due to not being able adjust the bed. On April 10,2025 between 9:45am and 10:15am LPA Lee interviewed Administrator (A1) Peggy Clark who denied the allegation stating that as soon as R1 complained about her bed not working, a message went out to our maintenance guy, and he fixed the bed that day. On April 10, 2025, between 11:00am and 2:00pm LPA Lee interviewed 3 staff regarding the allegation and of those interviewed 3 out of 3 staff denied the allegation stating that when R1 reported that the bed was not working, it was fixed the same day. On April 10, 2025 between 2:00pm and 3:00pm, LPA Lee interviewed 3 residents and of those interviewed 3 out of 3 residents stated that problems in the facility are usually addressed right away. On April 10, 2025, LPA inspected R1’s room and observed that the bed was operational as A1 demonstrated the bed was working by moving the head and feet sections in an up and down motion with the motor control. On April 23, 2025, LPA Lee interviewed R1 who stated that the bed is working fine and says that there is no problems with the bed. R1 informed LPA that there are no issues with R1's back as there are no sores on R1’s back as reported in the complaint. On April 23 2025, LPA obtained and reviewed a copy of R1’s body check (dated 4/19/25) which indicated no sores of any kind on R1’s back as reported in the complaint. Based on the information gathered, there is insufficient evidence to support the stated allegation. Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff did not ensure resident’s electrical outlet was fixed properly. The detail of the complaint alleges that the electrical outlet blew out has not been working for 3 weeks. On April 10,2025 between 9:45am and 10:15am LPA Lee interviewed Administrator Peggy Clark who denied the allegation stating that as soon as R1 complained about the electrical outlet by the bed not working, a message went out to our maintenance guy, and he fixed outlet that day. On April 10, 2025, between 11:00am and 2:00pm LPA Lee interviewed 3 staff regarding the allegation and of those interviewed 3 out of 3 staff denied the allegation stating that when R1 reported that the electrical outlet in the room was not working, it was fixed the same day. On April 10, 2025, LPA inspected R1's room and observed that the the electrical outlet was working. On April 23, LPA interviewed R1 who stated that the outlet is working. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED No deficiencies were cited for the above allegation. Exit interview was conducted. A copy of this report was provided to Peggy Clark, Administrator.

The investigation revealed the following: Allegation: Facility staff speaking inappropriately to resident in care. It is alleged that staff told resident, that if they didn’t start behaving, they would send the client away. On 10/21/24, the department conducted interviews with A1, S1-S,5 and R1-R12. 6 out of 6 staff interviewed denied the allegation. 6 out of 6 staff interviewed stated all residents are treated with respect. 11 out of 12 residents interviewed denied the allegation. 10 out of 12 residents interviewed stated that facility staff treat them with dignity and respect. 11 out of 12 residents interviewed stated they are satisfied with the facility and the services being provided to them. Based on the observation, a review of records, and interviews conducted, there was not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility staff did not meet the needs of resident in care. It is alleged that a resident asked staff for assistance back to their room after eating breakfast. Staff left resident unattended and without assistance in the TV room. On 10/23/24, the department conducted interviews with A1, S1-S5, and R1-R12. 6 out of 6 staff interviewed denied the allegation. 11 out of 12 residents interviewed stated they did not know of the allegation. 11 out of 12 residents interviewed stated that staff assist them with their everyday needs. 11 out of 12 residents interviewed stated they are satisfied with the facility and the services being provided to them. Based on the observation, a review of records, and interviews conducted, there was not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Administrator Peggy Clark, and a copy of this report was provided.

Continued LIC9099-C page 2 The department requested copies of the following documents: Personnel Report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Consent Forms, Replacement Appraisal Information, Appraisal and Needs Service Plan, Resident Progress Notes, Long Beach Memorial Hospital Medical Records, Windsor Convalescent Hospital Medical Records, Long Beach Police Department Call Log, Special Incident Reports, In-Service Training, Training on Reporting Dependent Adult and Elder Abuse, and any Ongoing Training. Allegation: Lack of supervision resulted in the resident falling and sustaining multiple injuries The department interviewed staff members 1-6 (S1-S6), residents 1-13 (R1-13), and witnesses 1-4 (W1-W4). Based on files, and interviews, there was insufficient evidence to prove that the facility was responsible for neglect or lack of care and supervision, leading to the resident's unwitnessed fall at the facility on June 22, 2024, which resulted in multiple injuries. According to the resident's medical records from Long Beach Memorial Hospital, the resident sustained a stroke, which may have contributed to the unwitnessed fall. Staff, the resident's physician, and witness statements indicated no change in the resident condition that would have raised any concern for the resident to fall. The resident was documented as ambulatory and able to dance during a replacement assessment on May 16, 2024. The resident's physician confirmed that upon discharge from Windsor Convalescent Hospital on May 25, 20024, the resident was ambulatory and walked with ease. The physician added that the resident frequently danced while at the hospital. Investigation revealed the following: Based on the evidence received from the medical records, staff, resident's physician, the residents, and witnesses there was sufficient staff on duty in the memory care unit at the time of the fall. Staff immediately responded to the resident's room upon hearing a loud sound, provided assistance, and called 911 promptly. The staff took all necessary precautions to assist the resident. The staff could not have prevented the resident from falling. The allegation of neglect lack of care and supervision leading to the resident falling and sustaining multiple injuries was unsubstantiated. See the continued LIC9099-C page 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued LIC9099-C page 3 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs, was provided to the Administrator Peggy Clark. There were no deficiencies cited. An exit interview was conducted

Regarding Allegation #1: Resident sustained fracture while in care of staff. It is being alleged that R1 fracture R1 hip while in care of staff. Toured the facility including R1 room. R1 room floor did not appear to have any wax on the ground. Incident report (dated 01/28/2024) R1 fell in room and was not injured. Incident report (dated 03/29/2024) staff noted R1 had leg injury and R1 was transported to St. Mary hospital for evaluation. S1 indicates that R1 was no longer living at the facility in June 2024. S1 indicates that there is no record of R1 falling on 06/08/2024. S1 indicates that St. Mary hospital records has R1 in room 255 on 03/29/2024 for infection of the left foot. S1 indicates that the hospital does not mention a fracture hip for R1. 4 out of 4 staff indicate that R1 never fracture R1 hip while in care of staff. R1 indicates that R1 was moving from R1 wheelchair to the bed. R1 indicates that due to a wet floor R1 fell and fracture R1 hip on 06/08/2024. 10 out of 11 residents indicate that they have never seen staff wax the floors or rooms. 10 out of 11 residents indicate that they have never fracture their hip. Regarding Allegation #2: Unlawful eviction. It is being alleged that R1 was evicted from the facility unlawfully. Reviewed 30-day notice of eviction, (dated 02/19/2024), effective date of eviction 03/19/2024, due to past due rent and late fees. S1 indicates that R1 was behind in R1 rent and stopped paying any rent since March 2024. S1 indicates that R1 was transported to St. Mary Hospital on 03/29/2024 and never returned to the facility. S1 indicates that a 30-day notice was generated on 02/19/2024 and effective 03/19/2024. S1 indicates that R1 was served the eviction notice by staff S5 while living at the facility. S5 indicates that S5 was given the 30-day notice of eviction and gave the notice to R1 prior to R1 being taken to the hospital on 03/29/2024. R1 indicates that R1 was transported to the hospital for a fracture hip on 06/08/2024. R1 indicates that R1 was released from the hospital. R1 indicates that the hospital informed R1 that R1 had been evicted from the facility and could not return. R1 indicates that R1 was never given an eviction notice from the facility. R1 indicates that R1 had not paid R1 rent and had text the facility owner to work out a solution but R1 never returned to the facility. 10 out of 11 residents have never received an eviction notice from the facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding Allegation #3: Staff did not assist resident in a timely manner. It is being alleged that R1 had fallen in R1 room and called for help from staff. LPA Calderon toured the facility to include room 134, 220, 277 and 282. One of the rooms inspected was R1 room. LPA pushed the call button and on average it took staff 5 to 10 minutes to arrive. Reviewed call log notes (dated 03/05/2024), there are no call logs from R1 room from March to June 2024. There is no incident report for 6/8/2024 for R1 falling and fracture R1 hip or R1 pressing the call button. 5 out of 5 staff indicate that on average it takes 5 to 10 minutes for staff to help once a call button is pushed. 5 out of 5 staff indicate that there is no record of R1 pushing R1 call button on 06/08/2024. S1 indicates that R1 was no longer living at the facility on 06/08/2024 and had been at St. Mary Hospital since 03/29/2024 for a foot injury. R1 indicates that on 06/08/2024 R1 fell and fracture R1 hip. R1 indicates that R1 pushed the call button for help, and it took staff 2 hours to arrive and call 911 for R1 to be taken to the hospital. 10 out of 11 residents indicate that it takes 10 to 15 minutes for staff to arrive once a room call button is pressed. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “resident sustained fracture while in care of staff”, “unlawful eviction”, “staff did not assist resident in a timely manner” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Veronica Gomez (S1).

This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and was assigned to Investigator (IB: Sonia Sandoval). The investigation included a review of Long Beach Police Department Non-Criminal Report (dated: 05/27/24);Long Beach Medical Center Medical Records (dated: 03/26/24 & 03/28/24), Green Meadow Hospice Medical Records (dated: 05/29/24), and Optum Airport Plaza Medical Records. Interviews of witnesses #1-#9 (W1–W9), Administrator #1 (A1), facility staff #1-#8 (S1– S8), and residents #1-#2 (R1-R2). INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Facility failed to seek medical attention in a timely manner. It is alleged that facility staff failed to seek timely medical attention for resident #1 (R1). The complainant reported on 2/02/24, (R1) was found in (R1’s) bedroom completely unclothed, vomiting, and bleeding from (R1’s) private parts. This investigation revealed that Resident #1 (R1) sometime in January 2024 was sent out to the hospital due to having difficulty breathing and had blood in (R1’s) urine. (R1) was diagnosed with a Urinary Tract Infection (UTI). On 02/02/24, the facility informed family representative witnesses witness #1-#3 (W1-W3) that (R1) was complaining of abdominal pain. (R1) was transported by family member witness #2 (W2) to (R1’s) primary doctor and later transported by ambulance to Long Beach Medical Center Hospital Emergency Department and was examined. On 03/08/24, 03/26/24, 04/29/24, and 05/09/24 between 07:09 am – 04:20 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (9) out of (9) Administrator (A1) and staff #1-#8 (S1-S8) all verified they were aware of (R1’s) UTI health condition and occasionally would complain about abdominal pains. Interviews of staff revealed (R1) was discovered in (R1’s) room at approximately 07:00 am in bed with complaints of abdominal pain with bloody discharge and vomit. On 05/22/24, at 11:26 am, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed family member witness #2 (W2), who indicated (W2) received a call approximately between 12:00 pm – 01:00 pm who was notified by the facility of (R1’s) urgent condition. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (W2) stated the facility staff only indicated (R1) was complaining of abdominal pain and did not indicate (R1) needed to be medically evaluated. Moreover, the staff withheld information about (R1’s) additional symptoms of bloody discharge or vomited. On 05/23/24 at 02:14 pm, Investigator Sonia Sandoval interviewed Long Beach Medical Center Medical Director witness #7 (W7) who stated (R1) was admitted at approximately 04:46 pm on 02/02/24. (R1) would have been in pain and (R1’s) prognosis would not have changed, however, (R1) may have been spared additional pain associated with (R1’s) prognosis of Spinal Muscular Atrophy (SMA) if (R1) was brought in for medical attention much earlier. Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in “Facility failed to seek medical attention in a timely manner” is found to be SUBSTANTIATED. Allegation #3: Facility staff failed to report an incident to licensing. It is alleged that facility staff failed to report an incident involving resident #1 (R1) and resident #2 (R2). The complainant reported the facility staff failed to provide an appropriate level of care and supervision, which resulted in (R1) being sexually assaulted by (R2) on 02/02/24. There was no report of the incident to Community Care Licensing (CCL). On 04/29/24 at 12:49 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed Administrator (A1). (A1) indicated as the administrator, (A1) was responsible for submitting Special Incident Reports (SIR) to (CCL) and overseeing the facility. (A1) indicated there were cameras in the common areas and hallways, which are only accessible to management. (A1) indicated the cameras are not monitored daily, and it is only reviewed when incidents occur to assist with the completion of (SIRs). However, if incidents were not reported then the cameras would not be reviewed. (A1) indicated on 02/02/24 the morning staff informed (A1) of the incident between (R1) and (R2). (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 02/16/24, the Department conducted a health and safety inspection visit at the facility. During the inspection (A1) provided copies of Special Incident Reports (SIR) associated with (R1 and R2) (dated: 02/02/24 and 02/15/24). The facility has not revealed its submission of these incidents to (CCL) via fax receipts (also known as confirmation pages). Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in " Facility staff failed to report an incident to licensing" is found to be SUBSTANTIATED. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Peggy Clark and a hard copy of the report along with appeal rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and was assigned to Investigator (IB: Sonia Sandoval). The investigation included a review of Long Beach Police Department Non-Criminal Report (dated: 05/27/24); Long Beach Medical Center Medical Records (dated: 03/26/24 & 03/28/24), Green Meadow Hospice Medical Records (dated: 05/29/24), and Optum Airport Plaza Medical Records. Interviews of witnesses #1-#9 (W1–W9), Administrator #1 (A1), facility staff #1-#8 (S1– S8), and residents #1 #2 ( R1-R2). INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident was sexually assaulted while in care. It is alleged that facility staff failed to provide an appropriate level of care and supervision which resulted in Resident #1 (R1) being sexually assaulted by Resident #2 (R2) on 02/02/24 while in care at the facility. On 03/08/24, 03/26/24, 04/29/24, and 05/09/24 between 07:09 am – 04:20 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (9) out of (9) Administrator (A1) and staff #1-8 (S1-S8) who were not able to validate that a sexual assault had occurred between (R1) and (R2) on 02/02/24. Six (6) out of nine (9) facility staff have never witnessed (R2) inappropriate or aggressive behavior with other residents or staff. The Long Beach Police report revealed the facility staff provided inconsistent statements to law enforcement. When interviewed by Investigator Sonia Sandoval, Staff #1 (S1) admitted knowledge of the incident despite initially denying knowledge to law enforcement. The police report indicated Long Beach Police Officer (LBPO) witness #8 (W8) asked (R1) if (R2) had been assaulted or raped by (R2) and (R1) stated, “No.” On 03/25/24, 04/16/24, and 05/22/24 between 08:09 am – 03:15 pm, Investigator Sonia Sandoval of the California Department of Social Services Investigation Bureau interviewed (4) out of (4) family representative witnesses #1-#4 (W1-W4) revealed they never observed anything concerning with the level of care or supervision. (Evaluation Report continues LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 05/23/24 at 02:14 pm, Investigator Sonia Sandoval interviewed Long Beach Medical Center Medical Director witness #7 (W7), who confirmed (R1) underwent a thorough examination upon admission and the tests completed would have captured signs of trauma or bruising were not present. Furthermore, the additional symptoms (R1) exhibited at the facility may have been symptoms associated with (R1’s) diagnosis. On 06/26/24, at 07:57 am, Investigator Sonia Sandoval interviewed Long Beach Police Department Special Victims Section Detective witness #9 (W9), who claimed the investigation had been closed since no proven crime had occurred. There were no actual witnesses to validate that a crime had happened nor demonstrative evidence presented as evidence. Based on the evidence gathered interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: “Resident was sexually assaulted while in care” is found to be UNSUBSTANTIATED. An exit interview was conducted with Peggy Clark, and a hard copy of the report is provided.

Allegation: Staff does not have adequate training to care for residents. It is alleged that staff does not have adequate training to care for resident, complainant states that staff S1 is the real problem and does whatever and threaten to fire various caregiver. On 07/30/2024, records reviewed showed S1 had forty hours of mandatory training of care giver for residents. LPA interviewed seven(7) staff members (S1-S7) 7 out of 7 staff denied the allegation. LPA interviewed the assistant administrator S2. S2 stated that they have the required knowledge for providing care and supervision needed to the residents. LPA interviewed seven staff (7) (S1-S7) all of whom stated that they were given on-the-job training and forty-hour training and have the appropriate experience, which provides knowledge and skills to perform their jobs safely and effectively. S2-S7 stated that S1 never threatened to fire them. This is the first-time hearing something like that. LPA interviewed ten residents (R1-R10) 8 out of 10 denied the allegation and overwhelmingly stated that they are well cared for. Based on interviews, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. Continue LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff cannot communicate with the resident due to the language barrier. It is alleged staff cannot communicate with residents due to the language barrier. LPA interviewed ten (10) Residents (R1-R10) 9 out of 10 stated that they did not have an issue communicating with the staff; when they needed help, the staff did help them. LPA interviewed ten (10) residents (R1-R10) 9 out of 10 stated that when they need help the new staff do help them. On 07/30/2024, the department had no issues communicating with the staff during the visit. During interviews with seven (7) staff members (S1-S7), all the staff were asked if they had any issues communicating with residents, 6 out of 7 staff, denied the allegation and stated they had no problems communicating with residents. LPA interviewed ten residents (R1-R10) and asked if they had any preferred language spoken to them. All the residents, 10 out of 10, stated that they do not have any preferred language as long as the staff helps them when they need help. Based on interviews, observation, and information received, there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. No deficiencies cited. Exit interview was conducted a copy of the report was provided to assistant Administrator Peggy Clark.

Interviews revealed that four (4) out of six (6) staff and eleven (11) out of thirteen (13) residents have denied the allegation has taken place. Record reviews revealed that the subject of the complaint has completed additional training on 04/24/2024 and that the subject has adequate training for their position. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

During a previous visit conducted by LPA Senaha on 04/04/22, LPA Senaha conducted a plant inspection of the facility, received a copy of the Resident Roster, Staff roster, and documents for Residents R1-R4. On 04/01/22, the El Segundo Adult Senior care referred the above assignment to the Investigations Branch. It was accepted as an assignment to interview Resident R1 and administrator. Investigator Laura Garcia conducted interviews with the former Administrator on 04/05/22 and R1 on 06/01/22. The investigation revealed the following: Allegation: Resident assaulted another resident It is alleged Resident R1 was ‘beat up’ by resident R2 resulting in R1 being transported to the hospital for injuries. During an interview with the former Administrator, conducted by Investigator Laura Garcia, stated R1 is a wanderer and wandered into R2’s room while they were asleep. R2 woke up, was startled, and pushed R1 who fell. During file review, LPA reviewed a Special Incident Report (SIR), that was submitted regarding the incident that stated Saff was performing rounds and when R1 was not in their room Staff started to look for R1 and was calling their name, when they heard a R1 cry out loud. Staff observed R1 coming out of R2’s room. R2 said they were asleep, got startled, and pushed R1. The Long Beach Police Department was called out and the responding officer did not make a report due to the nature of the incident. During record review of Resident’s R1 and R2’s Physician Report, Needs and Service Plan, Resident Appraisal, and Staff Notes, LPA observed neither resident has a history of aggressive behavior, nor any previous altercations with other residents. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During interviews with Staff S1-S8, were asked if physical altercations occur between residents, eight (8) out of eight (8) stated physical altercations do not usually occur they have had verbal altercation on occasion. Additionally, staff S1-S8 were asked how they de-escalate altercations between residents, eight (8) out of eight (8) stated they separate the residents and talk with them till they calm down, and in many instances when asked what the altercation was regarding, they don’t remember. During interviews with Residents R3, and R5-R16, were asked if they have had, observed, or heard of altercations between residents, eleven (11) out of thirteen (13) stated they have not had, observed, or heard of any altercations. Additionally, three (3) of the thirteen (13) stated they have heard residents yelling at each other and staff come right away. During an interview with Resident R1, conducted by IB Investigator Laura Garcia, was asked about neglect/lack of supervision leading to physical abuse, R1 denied any type of abuse or neglect while residing in the facility. R1 stated “I was fine, they took care of me, I have no complaints.” During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Director of Admissions, Mary Salcedo, and a copy of this report was provided.

The investigation revealed the following: Regarding the allegation “Staff did not assist resident in a timely manner” it is being alleged that the facility’s front desk did not answer R1’s call and that facility staff did not come to R1’s assistance in a timely manner. LPA Leandro interviewed R1 and R1 indicated that she did not call front desk when she fell in her bathroom, and she does not call facility because they do not help her. Interview with Caregiver that assisted R1 indicated that R1 informed Caregiver that R1 did not call anyone for assistance. Interviews conducted with residents and staff indicate that staff makes rounds every 30 minutes to 3 hours. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. The investigation revealed the following: Regarding the allegation “Staff did not meet resident's needs,” it is being alleged that the facility did not move R1 to a room without a shower tripping hazard. Record review indicates that facility staff moved R1 to four different rooms due to R1’s request. LPA did not observe a shower tripping hazard in R1’s room. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was left with the Administrator.

On 04/01/22, the El Segundo Adult Senior care referred the above assignment to the Investigations Branch. It was accepted as an assignment to interview Resident R1 and administrator. Investigator Laura Garcia conducted interviews with the former Administrator on 04/05/22 and R1 on 06/01/22. The investigation revealed the following: Allegation: Staff do not supervise residents resulting in multiple falls It is alleged as a result of being short staffed resident fall due to lack of supervision. During file review, LPA reviewed Special Incident Reports (SIR) regarding falls. During the facility tour, LPA observed some rooms have a lower bed to make it easier for residents to get in and out of to help prevent falls. Additionally, LPA observed some rooms have fall mats that are placed next to the bed once the resident is in bed. During interviews with Staff S1-S8, were asked how often are residents with fall plans checked on, eight (8) out of eight (8) stated they are checked every fifteen (15) minutes. During interviews with Residents R3, R5-R16, were asked if they have had any falls while living in the facility, nine (9) out of thirteen (13) stated they have not had any falls while living here. Three of the four residents who experienced falls stated the falls happened years ago, and the other stated theirs was a minor fall. Additionally, during interviews with Residents R3, R5-R16, were asked if they feel staff supervise residents, thirteen (13) out of thirteen (13) feel staff supervise residents. CONTINUED ON LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Resident care needs are not being met. It is alleged resident’s needs are not being met and are not being changed or bathed in a timely manner. During the facility tour, LPA observed the residents in the facility are placed in a room in a certain area depending upon their needs. There are three (3) memory care units, a hallway of resident that are on hospice, an assisted living area, and an independent living area. Each area is staffed with caregivers according to the resident’s needs. LPA reviewed the Physicians Report, Appraisal, and Needs and Service Plan for eight (8) residents and reviewed where their placement is at in the facility based on the level of assistance they require. During interviews with Staff S1-S8, were asked if they feel residents care needs are being met, eight (8) out of eight (8) stated they believe residents care needs are being met. During interviews with Residents R3 and R5-R16, were asked if they felt their care needs are being met, thirteen (13) out of thirteen (13), stated their care needs are being met. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility failed to safeguard resident’s property It is alleged residents are missing personal items such as jewelry. During the facility tour, LPA observed in residents’ room a drawer with a lock on it to secure their personal belongings. During record review, LPA reviewed the Admission Agreement that states on page 8 number 27 “the resident or representative have the option to record and document all personal property brought into the facility on LIC621 for the facility to safeguard resident personal belongings and other property.” Additionally, it states “The facility is not liable for any personal items which are not contained in the resident inventory list.” During an interview with the Administrator S1, was asked how resident’s personal belongings are safeguarded, S1 stated every room has a locked drawer to secure their personal belongings in and the family is asked to inventory items coming in on a LIC621. Additionally, S1 stated that they tell new residents and their family not to bring expensive jewelry or large sums of money to the facility. During interviews with Staff S2-S8, were asked how residents personal belongings are safeguarded, seven (7) out of seven (7), stated they encourage residents to close and lock their room doors, and to secure items in their drawer with a lock. During interviews with Residents R3, R5-R16, were asked if they had any items go missing, ten (10) out of thirteen (13) stated they have not had any item go missing. Additionally, LPA asked the Residents R3, R10, and R16, what items they had missing and how long ago, a resident stated they had two (2) pieces of computer paper go missing a long time ago, another stated they had seashells go missing a while ago, and another stated they has some clothes go missing 3 years ago. During the course of the investigation, LPA was unable to find evidence to support CONTINUED ON LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Facility is short staffed It is alleged most days the facility is short staffed, one caregiver for each floor and in some cases one caregiver for the entire building to the point residents are assisting other residents with care and mobility needs. During record review LPA reviewed the Staff Schedule and observed there were eleven (11) caregivers scheduled to work. Additionally, LPA reviewed the staff schedule for April 2022 and observed for the AM shift seven (7) caregivers and a Med Tech was scheduled, for the PM shift ten (10) caregivers were scheduled and a Med Tech, and for the Noc shift five (5) caregivers were scheduled. During the facility tour, LPA observed all eleven (11) caregivers throughout the facility. During interviews with Staff S1-S8, were asked if they feel there are enough staff to meet residents needs, eight (8) out of eight (8) stated yes, they feel there are enough staff. During interviews with Residents R3, R5-R16, were asked if they feel there are enough staff to meet the residents needs, twelve (12) out of thirteen (13), stated they feel there are enough staff to meet their needs and one resident was not sure. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility has a lack of supplies It is alleged the facility is often low on supplies, diapers, and other care products. During the facility tour, LPA observed four (4) different rooms with hygiene supplies and incontinent care supplies stored within. LPA observed an ample supply of products. During an interview with Administrator S1, was asked if they feel there is enough supplies to meet resident’s needs, S1 stated they order products monthly and are always available to residents. Additionally, diapers are covered by the insurance and there are extra available if needed and hospice usually supplies wipes which we have extra available as well. During interviews with Staff S2-S8, were asked if they feel there is enough supplies to meet resident’s needs, seven (7) out of seven (7) stated the facility has hygiene products and incontinent products available for residents. During interviews with Residents R3, R5 – R16, were asked if hygiene or incontinent products are supplied to them, thirteen (13) out of thirteen (13) stated they know there are products available if they need them and the facility has a large supply. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today's visit LPA did not observe or cite any deficiencies. LPA conducted an exit interview with Executive Director, Veronica Gomez, and a copy of this report was provided.

On 08/10/23 Licensing Program Analyst (LPA) Mario Leon initiated a complaint visit for the allegations listed above. Today’s complaint investigation was greeted by, and conducted with, Veronica Gomez, Administrator. LPA explained the purpose of the visit. The investigation consisted of the following: LPA attempted contact with the reporting party (RP), who was unavailable. LPA toured the facility and interviewed three (3) clients, two (2) staff and one (1) witness. LPA requested facility records and staff records. Allegation(s): Due to staff negligence, resident did not receive medications. Staff are falsifying resident records. The investigation revealed the following: Regarding the allegation "Due to staff negligence, resident did not receive medications,” and “staff are falsifying resident records,” it is being alleged that R1 left the facility on 07/19/23 and staff notated on the EMAR that R1 took R1’s 8:00 AM and 12:00 PM medication. RP stated that during this time, R1 was away from the facility and did not receive medication. Record review reveals that R1 did not take R1’s 8:00 AM nor 12:00 PM medication on 07/19/23. The EMAR revealed that R1 only took 8:00 PM medication on 07/19/23. Interviews conducted reveal: 10 out of 12 staff members indicate that when families or residents provide notice of a facility departure, MedTech will prepare medication and leave at the front desk to ensure that residents do not miss their dose(s). Three (3) out of four (4) resident interviews, including R1, indicate that medication is provided when they need to leave the facility for a great length of time. LPA Leandro’s resident interviews reveal: 5 out of 8 residents, including four (4) from memory care, were unaware of the medication release process. Regarding the allegation “Due to staff negligence, resident did not receive medications," and “staff are falsifying resident records,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for these (2) allegations. Continue to LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation(s): Due to staff negligence, resident did not have blood sugar checked. The investigation revealed the following: Regarding the allegation " Due to staff negligence, resident did not have blood sugar checked,” it is being alleged that R1 did not have R1’s blood sugar tested the last two days. RP called on 07/31/23. Record review reveals that R1’s blood sugar was tested on 07/29/23 and 07/30/23. Blood sugar was not tested on 07/31/23. On 08/10/23, LPA Mario Leon interview with License Vocational Nurse (LVN) (S3/W1) indicated that R1 refused to be tested. The facility has a numbering system and S3/W1 was on number 5 and R1 had number 11. S3/W1 informed R1 that S3/W1 was unable to immediately assist R1. Then R1 refused. Based on record review and interview, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator Peggy Clark.

On 03/19/23, Licensing Program Analysts (LPA) Mario Leon, Regina Cloyd and Troy Watson, along with licensing program manager (LPM) Ulysses Coronel, conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs and LPM met with the Administrator Peggy Clark and assistant administrator Veronica Gomez and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10 residents. The facility is a large, two-story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which includes resident rooms, common areas, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living units. LPAs and LPM conducted record reviews of six (6) resident records and six (6) staff records. The facility disaster drill and fire drill were conducted during the day and night shifts on 02/13/24 and 02/15/24. The facilitys' disaster plan is current and in compliance with Title 22 regulations at the time of visit. LPAs and LPM checked resident units. Mattresses and box springs were in good condition, adequate lighting and plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting in the restroom, and sufficient toiletries are accessible to residents. Report continues, see LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The water temperature properly measured between 105-120 degrees F and the internal air temperature was comfortable, measured at 75 degrees F. Perishable and non-perishable food supply was checked and LPAs and LPM observed food to be fully-stocked at the time of visit. Carbon monoxide detector and smoke detectors were observed, fire extinguishers were fully charged as of 02/20/24, toxins and knifes were locked and inaccessible to residents. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Exits/Walkways around the facility were free of debris and hazards. LPA's observed a monthly schedule which presented a sufficient number of daily activities for facility residents. LPA observed the noted activities being conducted in the activities area, which is directly across from the TV lounge area. During today’s visit, there were three (3) technical assistance notes and two (2) technical violations provided; see: LIC9102AN and LIC9102TV. There were no deficiencies cited during today's visit. An exit interview was held with Peggy Clark and Veronica Gomez, Administrators, and a copy of this report and LIC9102AN's / LIC9102TV's were provided.

LPA observed three ALW personal rooms, all of which have a step to get in the shower. LPA interviewed 10 residents (R1-R10), seven (7) out of ten (10) residents have denied the allegation, one (1) resident out of ten (10) have denied the interview. LPA interviewed one (1) witness (W1) from Carelon Hospice and W1 has provided sufficient information to deny R1's fall was based on over-medication or any abuse. Record reviews revealed that resident one ambulated to the hospital via taxi service and that the radiology department observed no fractures throughout R1's body. Based on LPA's observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted with Veronica Gomez, Administrator (S1), and a copy of this report has been provided.

The investigation revealed the following: Regarding the allegation: " Resident sustained fractures while in care". It has been alleged that a resident (R1) fell while in care at the facility resulting in a broken (right) hip. IB’s interviews and record reviews revealed the following: On 02/08/2023, during R1’s admission at the facility, R1 walked without assistance and was not known to be a major fall risk. It was recommended that R1 use a walker for slightly unsteady gait and be supervised while walking. On 2/17/2023 R1 had a witnessed fall while ambulating at the facility and was sent to the hospital for assessment, R1 sustained a fracture due to osteoporosis and underwent hip pinning. On 3/06/2023, R1 returned to the facility after receiving physical therapy. Interviews revealed that R1 was not reassessed, despite having had a recent hip fracture and walking with a limp. S3 indicated that had R1 been reassessed, S3 also indicated that the facility would have requested “all the protective things” R1 would need. The facility moved R1 to a different memory care unit and placed R1 on Karemore Hospice on 3/16/2023. Despite these added services, R1 continued attempting to get out of bed without assistance and sustained unwitnessed falls in R1’s facility apartment on 5/14/2023 and 6/03/2023. In response, the facility staff placed pillows next to R1 and engaged the half bed rail to restrain future falls, but R1 was again not reassessed and R1’s responsible person was not notified of the falls. In addition, R1 continued ambulating without a cane and sometimes without supervision. It does not appear the facility requested safety equipment or other protective measures, aside from medication adjustment, and the facility did not provide sustained increased supervision despite claims to the contrary. Two days after R1 expressed pain following her fall on 6/03/2023, R1 sustained a minimally displaced left femoral neck fracture. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D. Regarding the allegation: "Resident sustained multiple falls while in care". IB’s investigation revealed the following: On 2/17/2023 R1 had a witnessed fall while ambulating at the facility and was sent to the hospital for assessment, R1 sustained a fracture and underwent hip pinning. On 3/06/2023, R1 returned to the facility after receiving physical therapy. Interviews revealed that R1 was not reassessed despite having had a recent hip fracture and walking with a limp. Due to changes in their medical condition, R1 continued attempting to get out of bed without assistance and sustained unwitnessed falls in R1’s facility apartment on 5/14/2023 and 6/03/2023. R1 continued ambulating without a cane and sometimes without supervision. The facility did not request safety equipment or implement protective measures, aside from medication adjustment. Report Continues, see LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) "Serious Bodily Injury" as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement. An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided to Peggy Clark, Administrator. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The investigation revealed the following: Regarding the allegation: "Resident sustained injuries while in care". Interviews and record reviews revealed that the contusion to R1’s right eye and forehead were sustained when R1 accidentally struck their bed rail due to agitation, as caregivers attempted to change R1’s incontinence briefs. Staff stated that R1 deliberately banged their head on the walls. R1 often required up to three caregivers to change their incontinence briefs due to R1’s high combativeness. On the early morning hours of 6/02/2023, while R1 was in bed, an overnight shift staff found R1 with blood on their mouth and teeth. Staff denied R1 sustained an unwitnessed fall. It is important to note that the caregiver moved R1’s legs up and placed pillows next to their body to keep R1 from getting out of bed. It is also important to note, for level of care purposes, that R1 had previously, at times, gotten out of bed and wandered about the facility. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report was provided to Peggy Clark, Administrator.

LPA interviewed six (6) staff (S1-S6). All staff have denied the allegation. LPA interviewed ten (10) residents (R1-R10). Seven (7) out of ten (10) residents have denied the allegation. Record reviews revealed that the subject had written a detailed note, explaining why they would not have completed the allegation listed above. Based on record reviews, interviews and observations conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There were no deficiencies cited during today's visit. An exit interview was conducted with Peggy Clark, Administrator, and a copy of this report has been provided.

The investigation revealed the following: Regarding the allegation: "Facility staff did not respond to residents' call buttons in a timely manner" It has been alleged that call notifications from the resident call buttons have gone unanswered or have taken an hour or longer for a response. On 11/08/23 LPA interviewed 9 residents and asked about their use of the call button and the general response wait time. During the interviews, seven (7) out of nine (9) residents disagreed with the allegation. LPA observed two (2) out of 9 call buttons in disrepair. A technical violation has been cited, see LIC9102TV. LPA interviewed 5 staff and all 5 staff have provided an adequate response as how they receive and respond to residents' call buttons and what alternate actions occur during an emergency. Based on the information collected, an inspection of the facility, observation, and interviews conducted, LPA found no evidence to support the allegation for this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Regarding the allegation: " Licensee does not ensure facility is adequately staffed at night to meet residents’ needs." It has been alleged that a resident had suffered from an unanswered call light, overnight. On 11/08/23 LPA interviewed 9 residents and asked about their experience with overnight staff. Six (6) out of 9 residents have denied the allegation. LPA interviewed three (3) staff regarding the allegation and all 3 staff have denied the allegation. LPA reviewed records provided, including facility staff roster and NOC shift for 11/08/23 - 11/09/23. During interviews with S1, S2 and PM shift staff Anthony DeLeon (S4), all three (3) staff have provided an adequate response at how NOC shift is properly covered and how the facility would respond if there were to be a deficiency of California Code of Regulations 87415(a)(3). Based on the information collected, an inspection of the facility, observation, record reviews, and interviews conducted, the Department found no evidence to support the allegation for this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated . An exit interview was held with Assistant Administrator, Peggy Clark, and a copy of this report was provided.